Podiatry Surgery Volume

[Stormblest]

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What would be considered a normal surgery volume for podiatry? Would like to hear how many cases a week on average practicing pods are doing. Specify if you are PP or hospital employed and if you take call. Also an estimate of how many cases are elective vs infection/trauma cases. Also how long you have been practicing.

I’ll start. Hospital employed and not exactly on call (rarely called after hours) but get inpatient consults frequently. On average probably do 2-4 cases a week, highest was 9 in one week. Probably 60% elective and 40% infection/trauma cases. I’ve only been out of residency for just over 2 years so I started out much slower but I’ve done about 250 cases in that time (little behind on my logging).

 

[josebiwasabi]

I am in academics but primarily clinical faculty, so my job essentially functions like a pseudo-hospital-employeed DPM. I am 8 years into practice.

Clinic 2.5 days, OR block 1 day, admin 1.5 days. I also frequently do inpatient add-on cases on my non-block days. We are on-call but the hospital rarely calls us in overnight. Call is roughly 1:4.

I do about 3-4 elective cases per block day. Inpatient cases probably about 2-3 per week on average. Recently have been a little busier, probably average 8-10 total cases a week. Historically my case diversity is about a 50:50 split elective/inpatient.

 

[Adam Smasher]

What would be considered a normal surgery volume for podiatry?

I think it's a bimodal distribution, with a smallish number of podiatrists who are very busy and maybe 20-30% operating seldom/not at all. And that makes sense, it follows the pareto principle. Those who are very efficient surgeons can do more of it, while it makes less economic sense for an office-based podiatrist to get out of the office to do even simple cases.

Personally I might do 4-6 cases/month in OR, plus another 4 minor-major procedures per month in office (ganglion cyst excision, exostectomy, certain hammertoes).

 

[heybrother]

I'm restarting/rebuilding my practice so I don't know what my surgical volume will be. It will assuredly be less than when I started 7 years ago and accepted every insurance. The most interesting thing to me about my volume though is that my surgical volume at one of my hospitals crashed when I started asking for reimbursement up front. I had a stretch where I was semi-regularly going to a hospital to do "Marketplace" BCBS plans. At times I was going there even more than my ASC. These cases were not worth much at all - perhaps slightly above Medicare. You could do multiple cases and still not collect $2000. No block so I'd routinely wait all day to get to go. Reviewed case load reimbursement and found that these cases were never paid in full. The case would be worth $400 and we'd only ever get $200. The second we switched to asking for full reimbursement up front - they just fell off the schedule like flies. You'd ask for $500-600 for a lapidus which was all you were going to get paid and suddenly your 3 case schedule surgery day would be zero. I fell like a jerk because my staff would schedule cases and then they'd be calling the week before to cancel.

There used to be a NY guy on here who was a bit argumentative but still interesting. I mentioned how at times I was going to a surgery center 3-4 times a month, but only doing 1-2 cases at a time. His immediate comment was - go once, do all the cases that day. He was right.

 

[msion]

Private practice here. Only half day/week for elective cases, so maybe just 1-2/week. I do get quite a bit of inpatient cases so average about 5-7 cases/week.

Elective surgeries are simply not worth it for private practice doctors. I do not need those meager $200-$400 surgeon fees. No ASC ownership so can't share the facility fees. It's basically charity care at this point.

I have somewhat a good arrangement for a block time for inpatient stuff. So doing a bunch of toe amps is actually finally worth it for me without getting delays. 0 day global period so I can bill the follow-ups as well.

I laugh hard inside when some HMO patients demand those new hammertoe implants they see online. Hammertoes pay so little. I make more by cutting those toes off.

 

[heybrother]

Private practice here. Only half day/week for elective cases, so maybe just 1-2/week. I do get quite a bit of inpatient cases so average about 5-7 cases/week.

Elective surgeries are simply not worth it for private practice doctors. I do not need those meager $200-$400 surgeon fees. No ASC ownership so can't share the facility fees. It's basically charity care at this point.

I have somewhat a good arrangement for a block time for inpatient stuff. So doing a bunch of toe amps is actually finally worth it for me without getting delays. 0 day global period so I can bill the follow-ups as well.

I laugh hard inside when some HMO patients demand those new hammertoe implants they see online. Hammertoes pay so little. I make more by cutting those toes off.

Have you ever been offered a chance at ASC ownership? There's an infrequent poster on here who feels ASC ownership has been life changing for him. I've never been approached or asked about it.

Sort of curious how your arrangement works because it feels like generating 5-7 inpatients cases would require quite a bit of hospital/inpatient work which would be even less efficient than ASC cases?

 

[msion]

Have you ever been offered a chance at ASC ownership? There's an infrequent poster on here who feels ASC ownership has been life changing for him. I've never been approached or asked about it.

Sort of curious how your arrangement works because it feels like generating 5-7 inpatients cases would require quite a bit of hospital/inpatient work which would be even less efficient than ASC cases?

I am in a big metro area so all the good ASC ownership opportunities are pretty much gone. There are new ASCs popping up from time to time but they all went belly up after a few years. The established ASCs are all with affiliated ortho groups that offer shares.

For inpatient stuff I have 2 nights reserved for pus cases. They are all from simple ER consults. Toe ulcer with osteo --> toe amp. Stuff like that. Get these cases booked right away. I see patient before surgery to confirm. Can knock out a few amps that way. They then get discharged the day after to follow-up in clinic for suture removal. Rinse and repeat. Between consults and the actual cases it pay well for one night. Definitely way less work and emotional stress than bunions and hammertoes. No need to wear lead so less stress for my neck. These poorly controlled diabetics are not working anyway so no work forms or disability stuff to fill out.

 

[DYK343]

Jan 1st through June 30th I did 162 surgeries. So about 6.75 a week.

Probably 2/3 pus bus and 1/3 elective stuff (scant trauma).

Some weeks are 10+. Some weeks are pretty slow (I only had 1 inpatient case all last week on call).

Just depends on what comes through the ER.

 

[Toenail]

Hospital employed. Day call mainly. About 9 cases per week. 50% pus, 40% elective, 10% fractures

 

[air bud]

Hospital employed. 3- 5 elective cases but usually bigger cases. Zero reason to do single hammertoes....a neuroma is a time suck. Very slow OR turnover. Flatfoot, scope lateral ankle stab, MIS retro. Probably do more rear foot than forefoot. Inpatient is random. Sometimes nothing for 2 weeks then 3 or 4 in 1 week. Comes out to about 25- 30 cases a month. Take call when I want which is basically M- F. Just me, no other surgical pods in the area.

 

[wakaflocka88]

MSG
2 block OR days a week at ASC, minimum 5 each day, PAs will help add on fractures on those days

Turn over time less than 15 mins, sometimes I get two ORs. RNFA closes and splints for me. She does really nice Alogower-Donati closures and patients complement on the aesthetics months later. I give her all the credit. I like to enjoy my life outside of work

It took me a while to become efficient and proficient but very fortunate because of the volume on a weekly basis. Without consistent repetition it’s hard to achieve both above

 

[Hybrocure]

PP. No stake in surg centers. No hospital call schedule. Percentage cut as an associate even if I operate. Maybe 1-5 cases a month just from personal patients who need amps or electives.

Most of the bunions and such I see shop around looking for docs in town who will do them cosmetically. I don’t do that.

Most of my bunions and hammertoe consults who come in for actual pain do fine with conservative fixes and don’t end up needing surgery because I don’t pressure them into it. Those that fail conservative I operate on. But it’s few and far between honestly. It’s crazy how many bunion and hammertoe issues get fixed just by telling people to wear the right shoes.

Not much motivation to go to the OR. If I was working at a hospital system or some surgery funnel job that would be a different story. But in PP after an associate cut and insurance/taxes I have no desire to do a 100 dollar bunion or what have you.

On a side note - when I took hospital consults as an outside provider on faith or just to be nice if the EDs at hospitals im credentialed at called, it usually always resulted in a mess to actually get paid for my work. A lot of free work was done at the expense of my free time not in clinic.

 

[Aresnebula]

Wow all you guys operating so much makes me think how much my job sucks lol New associate about 2 months into practice. I am lucky if I get to do one case a month lol. I am hoping this isn't the trend in PP because I wanna open my own shop and be board certified.

 

[Stormblest]

MSG
2 block OR days a week at ASC, minimum 5 each day, PAs will help add on fractures on those days

Turn over time less than 15 mins, sometimes I get two ORs. RNFA closes and splints for me. She does really nice Alogower-Donati closures and patients complement on the aesthetics months later. I give her all the credit. I like to enjoy my life outside of work

It took me a while to become efficient and proficient but very fortunate because of the volume on a weekly basis. Without consistent repetition it’s hard to achieve both above

Sounds like a dream set up. This is how ortho does it.

 

[Boba Foot]

PP, probably 5-6 elective cases a month. Standard stuff. Added MIS in the last year, and it's working well. I used to do free call, but I no longer do. I kind of miss doing amps and infections because they're easy and it makes me feel warm and fuzzy inside when I can save someone's foot. However, it never brought in more than $2-3k a month, and I'm not sure that minus overhead is worth it to give up weekends. Also podiatry always gets the **** end of the stick with OR add ons so having to cancel and move clinic patients is probably not worth it in the long run. Probably better for business and reputation to not cancel and move patients last minute and piss them off. Or show up an hour late because the OR is dragging ass. If I'm going to do that, the hospital should be compensating me appropriately for call.

 

[footpainhealer]

Wow all you guys operating so much makes me think how much my job sucks lol New associate about 2 months into practice. I am lucky if I get to do one case a month lol. I am hoping this isn't the trend in PP because I wanna open my own shop and be board certified.

I mean, you're only two months into it. It's way too early to tell what your surgical volume will be. Also, are you even credentialed everywhere? Some of the places took 4 months after I started working to even get me on-boarded.

Also, something you have to take into consideration, is the location of where people practice. You and I are in extremely saturated areas. Not just saturated with podiatry, but also saturated with orthopedic surgeons that work on RF (general/sports/trauma), as well as actual foot and ankle ortho. A lot of these guys on here are rural or Midwest or south or Texas or wherever it may be.... where there are much less podiatrists, but also much less orthopedic surgeons that are willing to touch anything below the knee.

 

[wakaflocka88]

Wow all you guys operating so much makes me think how much my job sucks lol New associate about 2 months into practice. I am lucky if I get to do one case a month lol. I am hoping this isn't the trend in PP because I wanna open my own shop and be board certified.

Ortho wanted me to be as busy as them, hence starting me at 2 block days a week. But it took me over 2 years to finally consistently book out my schedule. For a while I only did one block day a week and used the other day for clinic to see more new patients. Even in a wRVU system, bulk of my money is still from clinic. Do good honest work and word will spread.

Network with PCPs at events, keep the referral base strong, and don’t be the one cocky TFP

But also ask yourself - do you really want to do certain cases? Or any electives at all? The amount of disability paperwork, documentation, head aches, non compliance, complications. I am selective on my elective patients to minimize the above

 

[air bud]

Ortho wanted me to be as busy as them, hence starting me at 2 block days a week. But it took me over 2 years to finally consistently book out my schedule. For a while I only did one block day a week and used the other day for clinic to see more new patients. Even in a wRVU system, bulk of my money is still from clinic. Do good honest work and word will spread.

Network with PCPs at events, keep the referral base strong, and don’t be the one cocky TFP

But also ask yourself - do you really want to do certain cases? Or any electives at all? The amount of disability paperwork, documentation, head aches, non compliance, complications. I am selective on my elective patients to minimize the above

You neglected to mention your cookie recipe

Wait until @Retrograde_Nail comes in here with his OR schedule....

 

[Retrograde_Nail]

I did 27 cases (not procedures) last week.

Hospital employed at level 1 trauma center. Lots of wounds, skin grafts, ex fix, charcot, muscle flaps. Trauma gives me the bad ankle fractures in the worst specimens. I do some elective but its mostly achilles work, lateral ankle stabs, ankle scopes and midfoot/rearfoot fusions.

I probably do forefoot work the least. Not that I can't, I just don't see those kinds of patients needing bunion/hammertoe work frequently.

I do about 5-10 TARs a year as well

 

[Toenail]

I did 27 cases (not procedures) last week.

Hospital employed at level 1 trauma center. Lots of wounds, skin grafts, ex fix, charcot, muscle flaps. Trauma gives me the bad ankle fractures in the worst specimens. I do some elective but its mostly achilles work, lateral ankle stabs, ankle scopes and midfoot/rearfoot fusions.

I probably do forefoot work the least. Not that I can't, I just don't see those kinds of patients needing bunion/hammertoe work frequently.

Every once in a while I get weeks like that and it’s brutal because of lack of support. Do you get a first assist and flip rooms? Were all of these cases at a main hospital? I try to do as much of the elective stuff as possible at the ASC because turnover/bumps at main are awful.

 

[Retrograde_Nail]

Every once in a while I get weeks like that and it’s brutal because of lack of support. Do you get a first assist and flip rooms? Were all of these cases at a main hospital? I try to do as much of the elective stuff as possible at the ASC because turnover/bumps at main are awful.

I have an NP that closes and puts on wound vacs, splints, etc. This allows me to exit and start the next case and bounce back and forth quicky. Since my volume is high and the hospital wants me out as quickly as possible they give me a 2nd room. I do them at the main OR. Its a trauma center so turnover is fast because we have a lot of staff. Not typical for 99% of podiatrists but it is possible at these mega big hospital systems.

 

[Adam Smasher]

Wow all you guys operating so much makes me think how much my job sucks lol New associate about 2 months into practice. I am lucky if I get to do one case a month lol. I am hoping this isn't the trend in PP because I wanna open my own shop and be board certified.

I have a good friend who became very busy and accomplished in practice, ultimately became RRA certified if that matters. He spent his first year doing nothing but amps and I&Ds, so starting out slow is normal

 

[Weirdy]

PP. No stake in surg centers. No hospital call schedule. Percentage cut as an associate even if I operate. Maybe 1-5 cases a month just from personal patients who need amps or electives.

Most of the bunions and such I see shop around looking for docs in town who will do them cosmetically. I don’t do that.

Most of my bunions and hammertoe consults who come in for actual pain do fine with conservative fixes and don’t end up needing surgery because I don’t pressure them into it. Those that fail conservative I operate on. But it’s few and far between honestly. It’s crazy how many bunion and hammertoe issues get fixed just by telling people to wear the right shoes.

Not much motivation to go to the OR. If I was working at a hospital system or some surgery funnel job that would be a different story. But in PP after an associate cut and insurance/taxes I have no desire to do a 100 dollar bunion or what have you.

On a side note - when I took hospital consults as an outside provider on faith or just to be nice if the EDs at hospitals im credentialed at called, it usually always resulted in a mess to actually get paid for my work. A lot of free work was done at the expense of my free time not in clinic.

Single man operation and ditto this.
Tons of super groups around me.

And again- the ER/ hospital calls/ visits were pretty much charity. We'd try to bill out of network and get nothing.
The local hospitals also don't respect DPMs at all. Cases continually getting bumped even with the local supergroups, no paid call, list goes on and on.

Patient may or may not follow up but guess what- they're train wrecks who don't heal anyways.

Little desire to operate unless its necessary. Most bunions coming in have been 50/50 need vs cosmetic want.

I feel zero guilt turning down surgery and complex ankle deformities. Usually send it to the other surgical DPM or ortho guys who are nice and do good work.

Some call me a chicken.

I've done enough free work and spent enough time away from my wife and kid.

If I can continue to provide value with in office procedures and non op visits- I have a reason to exist.

 

[Toenail]

This comes as no surprise, as foot surgery is a waste of time in most PP settings.

 

[Bluecollarmed]

2 years out. CAH employed. It varies and is a little slower during summer for elective stuff but I’m between 12-20 per month. More ankle fractures than bunions at this point. One OR day per week with flip rooms but no NP/PA help. My clinic is typically 15ish per day of MSK complaints. Rare inpatient infection cases which is a little surprising but I’m not mad about it.

 

[Feli]

Looking at logs, I average 4-6 cases per month overall past few years in solo PP (roughly 75% elective cases).

^^I do nearly all of that on my one monthly block morning/day (was 2 days/month in years past).
It's probably 2-4 cases/mo most of the year, then 6-10 cases/mo in Nov/Dec deductible elective surg season (add more blocks, more cases).
I avoid inpt/ER infection cases as much as I can... now avoiding most fractures too as busy and winding down.
I think I had solid training and do pretty well at the cases I do, but I'd definitely be a lot better with more volume (we all would).

...When I was working IHS, there was way more pus bus stuff and trauma, but ORs were also even less efficient... that was maybe 8-10 cases/month (most pus/amp).

...it really is a shame how overtrained most of us are for the meager volume of OR surgery that we do. Even much of the volume of "cases" we do is HWRs, I&D, pretty easy stuff. Most of use do less surgery in an average month than a F&A ortho does in a OR day; not joking. We'd be soooo much better funneling all OR surg cases to 20% or so of DPMs (dental model); they'd have much better volume and competence that way. Some big/super pod groups are smart enough to basically just do this on their own: send most to one or two guys in the group - esp the bigger recon.

 

[Aresnebula]

I mean, you're only two months into it. It's way too early to tell what your surgical volume will be. Also, are you even credentialed everywhere? Some of the places took 4 months after I started working to even get me on-boarded.

Also, something you have to take into consideration, is the location of where people practice. You and I are in extremely saturated areas. Not just saturated with podiatry, but also saturated with orthopedic surgeons that work on RF (general/sports/trauma), as well as actual foot and ankle ortho. A lot of these guys on here are rural or Midwest or south or Texas or wherever it may be.... where there are much less podiatrists, but also much less orthopedic surgeons that are willing to touch anything below the knee.

I am credentialed at surgery centers where I have operated only twice. Hospitals are still pending but still, I feel like I may not get the surgery numbers here and it might be worse if I open my shop. I am afraid that I am forgetting how to operate lol. Guess I gotta weigh what's important: board certification or location.

 

[wakaflocka88]

This is the biggest lie in our profession.

What other MD/DO surgical specialty operates less than 1-2 times a week? Never because that is their job: a surgeon

 

[DYK343]

I did 27 cases (not procedures) last week.

Hospital employed at level 1 trauma center. Lots of wounds, skin grafts, ex fix, charcot, muscle flaps. Trauma gives me the bad ankle fractures in the worst specimens. I do some elective but its mostly achilles work, lateral ankle stabs, ankle scopes and midfoot/rearfoot fusions.

I probably do forefoot work the least. Not that I can't, I just don't see those kinds of patients needing bunion/hammertoe work frequently.

I do about 5-10 TARs a year as well

How many hours in clinic a week are you doing if youre performing 26 surgeries a week? I get fast turnovers at your system which is awesome. But 27 is a massive amount of cases in 1 week - for any surgical profession. Especially if rearfoot because those tend not to be 10min cases.

 

[Retrograde_Nail]

How many hours in clinic a week are you doing if youre performing 26 surgeries a week? I get fast turnovers at your system which is awesome. But 27 is a massive amount of cases in 1 week - for any surgical profession. Especially if rearfoot because those tend not to be 10min cases.

I operate a full day one day a week and then do cases over lunch time almost every day or after clinic. I see about 25-40 patients a day 4x a week. My NP also sees patients during the same clinic day. I just have a very high volume practice. Out of my cases per week I would say may 40% are actually recon. The rest are infections and wounds which need repeated tune up and possible STSG. I don't mind all the limb salvage. Easy money

 

[footpainhealer]

I operate a full day one day a week and then do cases over lunch time almost every day or after clinic. I see about 25-40 patients a day 4x a week. My NP also sees patients during the same clinic day. I just have a very high volume practice. Out of my cases per week I would say may 40% are actually recon. The rest are infections and wounds which need repeated tune up and possible STSG. I don't mind all the limb salvage. Easy money

That is wild. How do you even have time to fill out the forms to book these cases, the FMLA, just the notes themselves from clinic, all the operative notes, the DME orders, etc. ?

Just that clinic volume alone is already 10 to 14 hours of work per day when you factor in having to do the notes and chart review and all that stuff. That's not even factoring in surgery and op notes and all the paperwork that comes with booking the actual cases, or call.

Do you have a scribe?

 

[Weirdy]

That is wild. How do you even have time to fill out the forms to book these cases, the FMLA, just the notes themselves from clinic, all the operative notes, the DME orders, etc. ?

Just that clinic volume alone is already 10 to 14 hours of work per day when you factor in having to do the notes and chart review and all that stuff. That's not even factoring in surgery and op notes and all the paperwork that comes with booking the actual cases, or call.

Do you have a scribe?

Assuming he's got admin/staff for all of that being hospital employed

Or just getgud bro

 

[Adam Smasher]

This is the biggest lie in our profession.

What other MD/DO surgical specialty operates less than 1-2 times a week? Never because that is their job: a surgeon

Certain FM providers do C-sections. The OR staff at my institution hates those cases because the attendings are traaaash

 

[Retrograde_Nail]

That is wild. How do you even have time to fill out the forms to book these cases, the FMLA, just the notes themselves from clinic, all the operative notes, the DME orders, etc. ?

Just that clinic volume alone is already 10 to 14 hours of work per day when you factor in having to do the notes and chart review and all that stuff. That's not even factoring in surgery and op notes and all the paperwork that comes with booking the actual cases, or call.

Do you have a scribe?

I have a team of nurses who do FMLA paperwork. They are hired by the ortho department to only do FMLA paperwork. My personal nurses do the DME paperwork. I have two nurses and one NP who work under me.

 

[Boba Foot]

They are hired by the ortho department to only do FMLA paperwork

God what a soul sucking job

 

[DYK343]

I operate a full day one day a week and then do cases over lunch time almost every day or after clinic. I see about 25-40 patients a day 4x a week. My NP also sees patients during the same clinic day. I just have a very high volume practice. Out of my cases per week I would say may 40% are actually recon. The rest are infections and wounds which need repeated tune up and possible STSG. I don't mind all the limb salvage. Easy money

Limb salvage is all I want because I too like easy money

 

[Retrograde_Nail]

God what a soul sucking job

Haha. They complain about the paperwork for my patients the most because my patients are the biggest complainers.

 

[Aresnebula]

Limb salvage is all I want because I too like easy money

Really? How? Charcot recon takes hours depending on what you are doing, not to mention if you apply frames, those can take up a lot of clinic time especially if you don't have enough staff. In terms of wounds, those get infected quick and next thing you know, ed is calling you because your patient is in the hospital and you gotta do an amp asap. Not to mention how incredibly noncompliant these patients are. Unless you are doing grafts and stuff then yeah, very good money.

 

[heybrother]

Really? How? Charcot recon takes hours depending on what you are doing, not to mention if you apply frames, those can take up a lot of clinic time especially if you don't have enough staff. In terms of wounds, those get infected quick and next thing you know, ed is calling you because your patient is in the hospital and you gotta do an amp asap. Not to mention how incredibly noncompliant these patients are. Unless you are doing grafts and stuff then yeah, very good money.

Dyk can do beautiful calcaneal fracture ORIFs, but just wants no global toe amps on RVU $$$.

 

[DYK343]

Really? How? Charcot recon takes hours depending on what you are doing, not to mention if you apply frames, those can take up a lot of clinic time especially if you don't have enough staff. In terms of wounds, those get infected quick and next thing you know, ed is calling you because your patient is in the hospital and you gotta do an amp asap. Not to mention how incredibly noncompliant these patients are. Unless you are doing grafts and stuff then yeah, very good money.

I dont do any grafts in clinic. None. Zero. Occasionally kerecis in OR for exposed bone/tendon. Grafts also pay hot garbage on wRVU. Grafts actually lose money whenever I put one on because application includes debridement and the debridement pays more than the graft on wRVU. I use them when indicated but only in OR - regardless of reimbursement.

2-5 times a year there is true nec fasc or something emergent. But almost all of what I get consulted on can wait until the next morning for my daily morning limb salvage block. Or monday morning if weekend.

I dont do tons of charcot. Theyre just absolute crap candidates for surgery 90+% of the time. But on a RVU system charcot is easy money. Frame is 16 wRVU + whatever fusions/TAL/etc you do. Can easily hit a half plus day wRVU production in clinic on one 2-3hr case.

I do a fair amount of amps/I&Ds and even more preventative/curative semi elective surgeries (kellers, plantar fasciotomies, elevating metatarsal osteotomies, gastroc recessions, flexor tenotomies, peroneal tenotomies, etc, etc). Many of which I still bill for wound debridement during global.

Split thickness skin graft is also $ for complexity/time.

Delayed primary closure is bank on wRVU but I dont use it as much. Im pretty ethical in my closure rates. Its over done IMO.

It helps I have wound RNs who do all my limb salvage dressings so my post op visits are easy. Talk to patient. Debride. Put in orders. Ask nurse for XYZ. Move onto next room. 5-10 min max.

I have next to no competition because all the DPMs in my area only want big ortho type cases. Its very competetive in that regard and there is some very well trained competition in my area. But good for me they smack talk limb salvage even harder than @Feli

Insurance doesnt matter. Im paid the same no matter the patients ability to pay.

A big thing is im already in the hospital. So ED calling me is a 1 minute walk. OR is a <1min walk. The medsurg floor is a 30 second elevator ride away.

Being in the hospital, wRVU reimbursement, with wound RNs makes the above scenario ~10,000 wRVU a year working 7-5 with no weekends.

One last thing, I have the ED "trained" to not call me in the middle of the night unless its bad. If its nec fasc they call me. But honestly I get woken up almost never. I just wake up at 530 every morning and check the list. Nothing new? Back to bed.

Dyk can do beautiful calcaneal fracture ORIFs, but just wants no global toe amps on RVU $$$.

So over that. I never want to go back to a trauma focused job. I can do it. But its not for me.

 

[dtrack22]

Charcot recon

Not generally what anyone means when they discuss wound care/limb salvage. At least around here. I&Ds, grafting, tenotomies, osteotomies, secondary closure, amps. Plus fewer people should be doing any Charcot recon anyways. If they can’t be offloaded in a crow or are non compliant with it, they are going to end up with a BKA. So skip the $30k+ frame and just have someone cut their leg off.

It helps I have wound RNs who do all my limb salvage dressings so my post op visits are easy. Talk to patient. Debride. Put in orders. Ask nurse for XYZ. Move onto next room. 5-10 min max

This is the way.

The only thing that extends my visits with patients in our wound care clinic is doing procedures. But that tenotomy plus the wound debridement is a little over 5 wRVUs or a little over $300 before taxes on my paycheck. And the tenotomy didn’t extend my visit by more than 5-10 min (I do have to wait for RN to get lido out of a Pyxis since a hospital based wound care clinic). And you can have 4-5 rooms running at once in that setting. My wound clinic day is more profitable than any of my ortho clinic days and most of my OR days.

Speaking of tenotomies, you guys know that perc TAL under local is worth less wRVU than a perc flexor tenotomy of a toe? Wild.

 

[air bud]

Yes limb salvage is not Charcot. Stupid is Charcot surgery

 

[Retrograde_Nail]

When discussing limb salvage surgery, charcot and wounds it really makes the most sense for hospital employed DPMS to be handling this as we have the most support and resources. I have an entire wound care clinic at my disposal.

I have wound care RNs on the floor who do all my wound vacs and pin site care for the frames. I can't remember the last time I did an ex fix dressing or wound vac change in the clinic.

I can also get patients into HBOT as quick as I want if they qualify. I can't tell you how many jams I've gotten myself out of because things were trending the wrong way and we got the patient into HBOT.

I also can get patients in vascular as quick as I want as well as I have the hospital employed vascular group and a private vascular group willing to take my patients whenever possible.

It's just a different ball game.

If I was private practice I would not dare try and treat these patients as the insurance reimbursement is not worth the headache. On a wRVU scale its well worth it.

 

[air bud]

When discussing limb salvage surgery, charcot and wounds it really makes the most sense for hospital employed DPMS to be handling this as we have the most support and resources. I have an entire wound care clinic at my disposal.

I have wound care RNs on the floor who do all my wound vacs and pin site care for the frames. I can't remember the last time I did an ex fix dressing or wound vac change in the clinic.

I can also get patients into HBOT as quick as I want if they qualify. I can't tell you how many jams I've gotten myself out of because things were trending the wrong way and we got the patient into HBOT.

I also can get patients in vascular as quick as I want as well as I have the hospital employed vascular group and a private vascular group willing to take my patients whenever possible.

It's just a different ball game.

If I was private practice I would not dare try and treat these patients as the insurance reimbursement is not worth the headache. On a wRVU scale its well worth it.

100% agree. There's a few Private practice people that I talk to from here and I'm consistently like dude there's no way you can treat this appropriately and in no way is it your responsibility or worth your time. Don't stress over how to treat them. Get them to somebody with more resources. That's your responsibility.

 

[Adam Smasher]

Mostly agree with comments above about punting anyone needing a frame. A lot of tenotomies etc are very doable in an average podiatry office. It depends on how committed you are to wound care, which if you're not interested in it you'll do it badly so don't try.

I will say, there are a couple of prestigious residency programs in my metro with limb-salvage attendings and I get SO much pushback when I try to send over my Charcot patients. I have a 0% success rate with CROW boots. They're too heavy, they don't ventilate so when patients' feet sweat it just pools around the ulcer. This is what is known in the French culinary tradition as confit style of cooking.

I've had patients with PAD and gangrene get transferred to tertiary care center, vascular over there does the bypass, and they get dc'ed back to my office with their gangrene toe still attached!

So I do the best I can, I'm transparent with patients about what I can and can't do. I had to invest a lot in my practice to have the resources to treat these people but it's decently profitable.

 

[BeaverBlade]

I'm with @Adam Smasher even the people with resources in my area don't like doing charcot. I'm also very honest with patients and sometimes I send them hours away. Also agree.... I don't think total contact casting/crow boots work well.... i've tried to conservative care them in office with proper offloading but i've had them macerate so quick and even ulcerate once the edema is improved. charcot is a cancer diagnosis essentially and patient's need to understand that. I don't know when the gold standard became total contact casting especially when there's a wound. it's going to get macerated/infected even if properly applied. someone prove me wrong? Yes let's take our highest risk patient and put them in a cast for a week with a wound.

private practice vs hospital employed is a different world. I also think it depends on the wound but also non charcot wound care in PP setting can be difficult. yes it reimburses well, but the energy per patient is quite a bit. and they always want free wound care supplies lol

also everything always comes back to vascular. if vascular in your area sucks in PP then you are setting yourself up for failure with a lot of wound care as you wait on vascular. it's a catch 22 because you know you're better at wound care than the general surgeon/primary doctor or whoever at the wound care center is doing it... but also you don't want your practice to be all wounds. I'm still learning how to handle this as PP owner

 

[josebiwasabi]

not that it's a 1 size fits all solution, but TTC nailing with MIS flipper foot has been pretty successful at our institution. relatively small incisions, less hardware, shorter OR times.

 

[Weirdy]

When discussing limb salvage surgery, charcot and wounds it really makes the most sense for hospital employed DPMS to be handling this as we have the most support and resources. I have an entire wound care clinic at my disposal.

I have wound care RNs on the floor who do all my wound vacs and pin site care for the frames. I can't remember the last time I did an ex fix dressing or wound vac change in the clinic.

I can also get patients into HBOT as quick as I want if they qualify. I can't tell you how many jams I've gotten myself out of because things were trending the wrong way and we got the patient into HBOT.

I also can get patients in vascular as quick as I want as well as I have the hospital employed vascular group and a private vascular group willing to take my patients whenever possible.

It's just a different ball game.

If I was private practice I would not dare try and treat these patients as the insurance reimbursement is not worth the headache. On a wRVU scale its well worth it.

I've had 3 Charcot walk into my clinic
Would've loved to send them to you if you were at the local hospital down the street.

I sent 2 to ortho
3rd most recent one doesn't understand the severity. I wrote his FMLA but he's about to go back to work. Not a stable foot. Doesn't get it.

Even in a podiatry super group I have not seen nurses doing dressing changes etc.
The rate people re-Charcot and how most of the salvage procedures I've seen end up in BKAs....makes zero sense for outpatient practice to manage these.

None of this is sustainable as a 1 man outpatient pp.

I work up as much of these train wrecks as possible when I have a chance because its the right thing to do.

In house labs. Stat referrals to specialists who I trust and are embedded in the hospitals. Stat imaging orders. Pick the medicine guys brains to optimize the patient. Take pictures and text my colleagues who have experience to see if there's anything else they would do differently.

I can only do so much until they end up in the ER

Long post to say I completely agree with you.

I used to get offended when my PD suggested a split track of non surgical + surgical pods with appropriate time of training for both.

Now I get why he said what he said.

 

[Weirdy]

not that it's a 1 size fits all solution, but TTC nailing with MIS flipper foot has been pretty successful at our institution. relatively small incisions, less hardware, shorter OR times.

I've seen the flipper foot work as well with TTC.

Some hate it cause hurrdurr wtf did you do to their midfoot its essentially non functional.

But hey they're wound free and its a weight bearing foot.....what more do you want.

Its a peg leg but its a functional peg leg.
Until they re-Charcot, the nail backs out, and it turns into washout/abx cement block/resalvage/ inevitable BKA.

 

[shadesofgrey]

Ditto on finding surgeons with interest in charcot sx. I have had 2 patients that I referred to a rather prestigious orthopod fellowship for possible charcot recon on unstable preulcerative foot. Both times referral came back no wound and no need for surgery, only to ulcerate within a month. Then, I **** you not, I send the patient's back for surgical evaluation, now with an open wound, and they said there's an open wound, we should wait until it's closed and sent back for wound care.

Very frustrating for patient and myself, I'm not sending you a stable charcot foot and asking for surgery. I'm sending it hoping you will prevent the disaster.